The mystery disease of Eluru

It has been 11 days since she suddenly collapsed and had a seizure, but Bantu Mallika’s woes are not over. The thirty-two-year-old homemaker from Temple Street in Eluru still gets shivers, headaches and dizziness.

It was on December 6 that Mallika felt a piercing headache and giddiness at home. Feeling disoriented, she called the village health assistant, Durga, for help. It was a timely call, for minutes later she lost consciousness and had a seizure. She was rushed to the medical centre at the end of the street.

 

“I don’t know what happened to me,” Mallika said. “When I opened my eyes, I found myself on a hospital bed in the Government General Hospital (GGH). I had followed my usual routine that day. I did the household chores and had more or less the same food and water that I have been having for years. And none of my family members had any problem.” Mallika was discharged on the same day after treatment.

Health assistant Durga too was surprised by the sudden attack. “Mallika had a five-minute seizure and complained of nausea after she gained consciousness. For the past couple of days, we have been monitoring her along with four others on the street who experienced similar symptoms. They still feel weak and complain of a vomiting sensation,” she said.

Also read: 170 hospitalised with unknown disease in West Godavari district’s Eluru

“Mallika and four others” quickly turned to scores of people and scores to hundreds. Confusion prevailed as there seemed to be no identifiable cause of this illness. For the people of Eluru, in West Godavari district, already living in fear of COVID-19, this was a bolt from the blue. Between December 5 and December 13, over 600 people had fallen ill and no one knew why. Only theories floated around. On December 10, the Andhra Pradesh government constituted a 21-member high level multi-disciplinary committee to investigate the disease that was affecting the people of Eluru, a city with a population of over four lakh and a hub of agriculture, commerce, aquaculture and export.

The initial days

Doctors at the GGH said the illness had in fact started impacting several people in mid-November. All the patients had the same symptoms: after experiencing giddiness, back pain, fits, vomiting, anxiety, loss of memory, and headache, they all collapsed. The patients were immediately tested for COVID-19, their reports showed ‘negative’. While the recovery rate was extremely high, people were shocked when one man died. The sudden outbreak grabbed global attention in the first week of December, with officials of the World Health Organization (WHO), the State and Central governments, and research organisations scrambling to find out the cause.

 

According to government records, a majority of the cases have been traced to JP Road, Vangayagudem, Dakshina Veedhi, Turpu Veedhi, Arundhatipeta, Kothapeta, Kobbarithota and Sanivarapupeta in Eluru. The first cases were reported from JP Road and Vangayagudem, according to hospital authorities.

Also read: Health experts chasing all kinds of leads

On December 9, GGH was buzzing with activity. It was the second consecutive day that a decline in cases was reported, yet the hospital was still admitting patients with similar ailments — at least more than two every passing hour. GGH Superintendent A.V.R. Mohan was busy attending calls from State and Central officials, journalists and staff members. Speaking to The Hindu, he said that there was no pattern in the answers of patients when they were asked what they imagined was the reason for the illness. Some said the episode struck after they drove, some said it happened after they ate, others, after they drank. The authorities were at sea.

Mohan said the illness broke out before December. Sporadic incidents were reported by some rural medical practitioners from the middle of November, he said, but no one suspected anything. Then the numbers began climbing from December 4, the hospitals began filling up with patients, and a 45-year-old man died on December 9. “However, that death cannot be directly attributed to the disease,” Mohan said. “The person fell in the bathroom and the cause of death was reported as a head injury. But of course, post-COVID-19, any such development is a matter of concern.” Some people even experienced seizures more than once, but they were treated and sent home, said Mohan.

Also read: Eluru poisoning | 561 people affected so far

The response

To handle the rapidly emerging crisis in Eluru, 150 additional people were brought from hospitals across the State, including doctors, paramedics and nurses. Expert teams from premier research and medical institutions in Delhi, Pune, Bengaluru, Hyderabad and other parts of Andhra Pradesh were also brought in.

 

Speaking to The Hindu at GGH, Jamshed Nair, Associate Professor at the Department of Emergency Medicine, AIIMS, New Delhi, said their team has collected inputs from the patients at GGH and visited the discharged patients and their kin in the affected colonies in Eluru. “We have collected blood samples from them. Samples of water and milk have been collected from Eluru and neighbouring villages for testing,” he said.

On its part, the government roped in administrative staff, police and medical personnel, and research institutions to handle the situation. Sixty-two village secretariats have been activated, and first aid centres have been set up in each locality. Each centre has a doctor and two paramedics and basic medication to help patients till the ambulance arrives. The Centre has maintained a log book of referred cases with details such as the name of the patient, ward, gender, symptoms noticed, the date of admission, the reference hospital, present condition, the mobile number of the patient, date of discharge and remarks. Such micro-level data has helped immensely in handling the situation, said the GGH Superintendent.

According to the data on Temple Street, where the first incident was reported, there were 17 cases recorded from December 5 to 9. While 13 of these patients had fits, the remaining complained of dizziness, weakness, vomiting and diarrhoea. The patients were referred to GGH, Swaruparani Hospital and Vijaya Diagnostics.

The government has established a round-the-clock control room and a call centre at the municipal office. According to officials, it initiated house-to-house surveys within municipal limits. So far, 42,012 households out of 43,897 have been scanned. To check the possible scarcity of beds, a speciality hospital was kept on standby in Vijayawada. Twenty ambulances were pressed into operation, and 300 beds and 150 doctors and nurses were kept ready for patients in GGH Eluru and Asram hospital. Food, milk and drinking water were supplied to all the patients. Specialist doctors from AIIMS were flown in to conduct a detailed investigation. Experts from the National Institute of Nutrition, Indian Institute of Chemical Technology, and Centre for Cellular and Molecular Biology were roped in to figure out the cause of the disease.

Possible cause

By December 10, potable water, cerebral spinal fluid, blood, and milk in the areas were tested and the CT scans of 42 patients were taken. Traces of heavy metals such as lead and nickel were found in the blood samples of patients, the AIIMS report said, but where they originated remains unclear. The Centre for Cellular and Molecular Biology has concluded that the locals consumed a neurotoxic contaminant that has caused the outbreak. The Director of the Centre for Cellular and Molecular Biology, Rakesh Mishra, said, “The Council of Scientific and Industrial Research and the Centre for Cellular and Molecular Biology carried out extensive analysis using the next generation sequencing-based approach to explore the microbiomes of samples collected from affected individuals. The samples included blood, faeces and vomitus. Our analysis showed no link between any infectious organism and this mysterious disease. The microbiomes were of healthy individuals. It is, therefore, likely that this disease was caused by a one-time event in a localised context and is not linked to any infectious organism. Considering the information available, it looks like a point-source outbreak where a neurotoxic contaminant has been consumed by the local people.”

Pesticide residue

The government constituted a multi-disciplinary high-power committee to investigate the source of the disease. The panel was also expected to suggest remedial measures to prevent any such event in the future. Headed by the Chief Secretary of Andhra Pradesh, the committee included doctors, scientists and senior officials from the Andhra Pradesh government.

The Chief Minister, Y.S. Jagan Mohan Reddy, announced on December 16 the findings of the expert panel through a video conference call and wanted further investigation into the issue. According to the details shared by the government, the probability that pesticide residues triggered the illness is high. AIIMS and the Indian Institute of Chemical Technology also agreed that this probability was high, but wanted further investigation on how the pesticides entered human bodies. The two institutes have been entrusted with the responsibility of carrying out further investigation. The Chief Minister also instructed the officials concerned to set up public labs in each district and continue the tests on food, water and soil so that the Eluru incident is not repeated. He wanted the agriculture department to focus on natural farming without using pesticides and help farmers with inputs through the Rythu Bharosa Kendras (RBKs). Over 10,000 RBKs were set up in Andhra Pradesh with the objective of helping farmers to enhance productivity while ensuring better incomes.

Various findings

Commenting on its findings, AIIMS, New Delhi stated that the blood samples of patients contained lead and nickel. All the milk samples that were collected also contained nickel. Based on the observations of patients, it said the reason for the illness could be the presence of organochloride which might have entered bodies through pesticides in the food cycle. Lead was also found in the blood samples of the relatives of the patients. AIIMS suggested that the food samples, food and vegetables be tested for a few months to help determine the exact reason for the illness. It also suggested geotagging of the samples.

The Indian Institute of Chemical Technology collected 21 water samples from different parts of Eluru along with blood samples from humans and animals. It found no traces of lead, arsenic or any other heavy metals and pesticides in the water samples. However, the blood samples contained endosulfan and dichlorodiphenyltrichloethane (DDT), which are hazardous. Blood samples also contained lead and there were no organophosphates present.

The National Environmental Engineering Research Institute, Hyderabad, which collected air, soil and ground water samples from the affected areas, said that the air quality is within acceptable limits. Except for mercury, all other metals and substances in surface and ground water are well within the limits. There were no traces of organochlorine or organophosphates in the samples. Compared to surface water, the ground water contained higher levels of mercury. The phenomenon was attributed to burning of solid waste in the region. The tests on soil are still underway.

The Centre for Cellular and Molecular Biology, Hyderabad, did not find any substances beyond the permissible limits in the serum and urine samples. There were also no traces of bacteria or virus, according to their report. The National Institute of Virology, Pune, said there was no evidence to prove any kind of viral infection. The National Institute of Nutrition, Hyderabad, found pesticide residues in the tomato and brinjal samples. These pesticides could have caused the mysterious illness, according to its report.

AIIMS, Mangalagiri, suggested a detailed examination and study of samples in other regions of the State against the backdrop of the Eluru incident. While investigating the presence of pesticide residues in humans, it wanted the right inputs to be given to farmers on the use of pesticides and natural farming. It has also suggested a detailed medical protocol to be used in the event of such an occurrence in the future.

The WHO representative wanted the expert panel to focus on how the pesticide residues entered human bodies.

Poor hygiene

Meanwhile, the public in Eluru feel that there should be a streamlining of pesticide and chemical usage and discharge of the same from agri and aqua processing sectors in and around the city. Though there were no formal complaints about the high and intensive usage of chemicals and pesticides, they expressed concern as Eluru is a major hub of aqua and agri exports. There are about 30 major aqua units which store, package, weigh and export aqua products such as shrimp and fish. These firms process, pack and export about 10,000 to 12,000 tonnes of processed product to different countries.

In December, the general hygiene conditions and management of garbage in Eluru are alarming. Almost all the canals are filled with garbage, still water, and plastic materials, which are a potential threat to general health. Eluru generates approximately 82 metric tonnes of garbage per day.

Several sources in and around Eluru leave effluents in irrigation and other canals which eventually seep into groundwater. The public spoke about industrial solid and liquid waste from aqua processing industries, effluents and pesticides mixing with water from aquaponds and agricultural patches. Eluru-based school teacher Sambasiva Rao said all the aqua industry certifications are upto the mark but there are violations. “The Marine Products Export Development Authority frequently conducts camps for aqua farmers on the excessive use of non-organic fertilisers, pesticides, insecticides and antibiotics. We know about the intensive use of pesticides in agriculture. All these are obviously sinking into soil and groundwater. It’s an open secret,” he said. Senior citizen and resident of Eluru, M. Satyanarayana, said, “Dumping garbage in open places and canals and water stagnation have become normal. There seems to be no tab on the use of pesticides and chemicals and discharge of different effluents here. This needs to change. The government should definitely focus on this aspect with commitment,” he said.

Meanwhile, with this illness causing fear among the people, eating out has become uncommon and public movement has reduced in Eluru, people said.

Residents also said people from other regions are now sceptical about visiting Eluru. B. Subbarao, a resident of Powerpet, said he noticed people being extra careful. “People are carrying their own water and eating out less. Fewer people are travelling to Eluru now. People have become suspicious of every small ailment. I had a headache a few days ago, and I was worried. But it turned out to be a normal headache. But the anxiety that something may happen to me is there all the time. I feel uneasy for no reason,” Subbarao said.

Doctors at GGH said that such mild paranoia is natural. “It’s common for the general public to take smaller illnesses more seriously and become anxious. We have had many cases at the GGH over the past few days where people who came for a check-up displayed high anxiety levels. It could be addressed in a matter of hours,” said GGH Superintendent Mohan.

The Andhra Pradesh State Health Minister Alla Kali Krishna Srinivas announced on December 13 that there were no new cases reported and all the 600 odd patients admitted in hospitals with symptoms of the illness were successfully treated and discharged. But the mysterious disease with no name has taken hold of people’s lives in Eluru. As trains near the Eluru railway station, passengers down the shutters. The sale of water bottles has reportedly seen a dip on platforms. It is as if the very air of Eluru has turned toxic.